Mechanisms of defense in clinical ethics consultation

For exceptions to the general rule, see Agich (2011); Shelton et al. (2016); Guerin (2020); Lanphier and Anani (2021).

It should be noted that stress exists not only for surrogates but for clinicians as well. See Embriaco et al. (2007); Vahedian-Azimi et al. (2019).

It is beyond the scope of this article to describe in detail how miscommunication and decisional occlusion may be derivative from defense mechanisms of healthcare professionals, not simply from patients or surrogates. Suffice it to say that the psychoanalytic literature is replete with discussions and examples of defense mechanisms on the part of the practitioner, what is often referred to as “countertransference.” See, for example, McLaughlin (1981).

For an explanation of decision-making capacity, see Appelbaum (2007).

For a more detailed summary, see Arnold (2014).

For a greater review of psychoanalytic literature on altruism, see Seelig and Rosof (2001).

On the topic of failure in working with defense mechanisms, Schafer is clear that one must always maintain a position of neutrality: “By what right does the analyst insist that the analysand do anything other than what he or she is doing?” He tells us that forcing the issue—“You’re being defensive”—is an impatient and intolerant stance that assumes a position of omnipotence and omniscience, certainly not a position that any analyst or ethics consultant should find herself in (see Schafer 1983: 168–171).

As Zaner puts it, “I sense neither that I have all along really been ‘up to something else,’ nor that I’ve been lusting for power or authority, nor that I am antidemocratic, nor that I possess an esoteric body of knowledge that others should (must?) respect and call upon, nor even that I am somehow better or more ‘expert’ than anyone else. To the contrary, as I’ve made a point by emphasizing many times, I honestly believe that I’ve been a privileged witness, time and again, to astonishing insights into what the moral order is all about, thanks especially to those people who invited and allowed me into their lives to listen and question, perhaps at times even to talk, as they struggled to make sense of what had happened to them, the decisions they had to face, ultimately, what their lives were all about” (Zaner 2015: 136).

To my knowledge, Richard Zaner is not a formally trained psychoanalyst.

I share the concern of Shelton and colleagues that among all the health professions clinical ethics consultants are not required to receive clinical training in basic counseling (Shelton et al. 2016: 29).

To the objection that there may not be senior ethics consultants with the requisite knowledge and skills, it seems plausible to assume that many senior ethics consultants acquire these skills through “(1) other forms of training such as social work or chaplaincy, (2) informal trial and error, or (3) being simply temperamentally adept at interpersonal interaction” (Shelton et al. 2016: 33).